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MultipayerStrategytoSupportPrimaryCareHomes

November5 ,2013

BackgroundStrong, effective primary care health homes are foundational to transforming and sustaining high quality healthcare for Oregonians.  Evidence shows that team‐based primary care will lead to better outcomes and drive down costs.  The more quickly Oregon can drive adoption of primary care health homes statewide, the more quickly we will drive achievement of the Triple Aim (improving care, improving health, and reducing cost). 

Oregon’s statewide primary care health home program is known as PCPCH (Patient Centered Primary Care Home).  PCPCH is a tiered approach representing increasing levels of primary care home attributes for a given practice.  A broad‐based, multi‐payer strategy is needed to support primary care homes statewide. Multi‐payer support will ensure that practices are compensated for the work they are doing to provide coordinated care, and supported in achieving outcomes through a robust and shared primary care home approach.  The Oregon Health Authority (OHA) and the Oregon Health Leadership Council (OHLC) convened a series of meetings from July to September 2013 that brought together payers and other key partners from around the state to develop consensus‐based strategies to support primary care homes in Oregon, facilitated and supported by the Center for Evidence‐based Policy.  Through the process, the organizations listed below agreed to the shared goals, objectives and initial key actions listed in this document.  

GoalMutual investment and commitment to accountable, sustainable, patient‐centered primary care 

that results in achievement of the triple aim. 

Objectives1. Simple, straightforward, and explainable payment models 

2. Payment policies will align 

Metrics 

Standards 

Quality 

Accountability audits 

Other support 

3. Meaningfully raise the bar in the delivery of quality care and outcomes for patients 

4. Allow for innovation, continuous improvement and movement to the triple aim 

5. Build on existing efforts and align with them where possible 

6. Facilitate and/or further provider transformation 

  2

ActionsTo reach the goals and objectives, payers agreed to the following initial joint actions: 

1. All Oregon payers will use a common definition of primary care home based on OHA’s 

PCPCH Program. (see attachment) 

2. Payers will provide variable payments, or other payment models, to those primary care 

practices in their network participating in OHA’s PCPCH program, based on each practice’s 

PCPCH points total and their progress toward achieving outcomes which lead to the Triple 

Aim.  Some payers may also require that practices meet specific thresholds or other 

conditions prior to qualifying for payments.  The structure, qualifications, and amount of 

these payments will be the responsibility of each payer to determine or negotiate with 

practices in their network.  

3. OHA’s PCPCH program will build in practice accountability for progress toward 

transformation. They will work with payers and practices to identify and agree on a 

common set of meaningful outcome metrics, consistent with those already in place for 

Oregon providers, as well as reporting formats and administrative processes that simplify 

the administrative burden on practices. 

4. The Oregon Health Authority, through its state health transformation efforts, has efforts 

underway to assist providers in achieving the standards of PCPCH, including the 

Transformation Center, site visits, and the Patient‐Centered Primary Care Institute. Payers 

will work with providers, purchasers, and other stakeholders to identify meaningful ways 

for further collaboration in order to support the long‐term sustainability of primary care 

homes. This group will specifically discuss efforts to engage self‐insured employers in 

primary care home efforts.  

5. Payers will convene to review the progress toward outcome metrics, and impact on total 

cost of care on at least an annual basis and determine whether adjustments need to be 

made to this payer collaboration or individual payer contributions based on the following: 

Whether cost savings and other outcome measures expected from this 

effort are realized. 

Whether practices are progressing according to the structure of the PCPCH 

program. 

Whether there is a need to convert some practices (e.g. established and 

high achieving practices or underperforming practices) to a different kind of 

reimbursement model. 

Whether new research reveals opportunities for improved practice 

transformation and cost containment. 

Whether shared savings or other payment models provide opportunities for 

reinvestment. 

Payers will also work with providers to review implementation strategies. 

Patient-Centered Primary Care Home 2014 Recognition Criteria

Quick Reference Guide Oregon Health Authority

Last Updated August 19, 2013

This guide is intended to provide a brief overview of Oregon’s Patient-Centered Primary Care Home (PCPCH) Program criteria for recognition that will be effective January 1, 2014. The technical specifications will be available mid-September 2013. Please refer to the following definitions when using this document:

Unchanged: The measure was part of the 2011 criteria. New: This optional measure was added to the 2014 criteria. (D): Data submission required.

The scoring system for the 2014 PCPCH recognition criteria remains the same. There are 10 must-pass standards that every recognized clinic must

meet. The other standards are optional, allowing clinics to accumulate points towards a total that determines their overall tier of PCPCH

recognition. A clinic’s overall tier of recognition is determined by the following:

Tier 1: 30 – 60 points and all 10 must-pass measures

Tier 2: 65 - 125 points and all 10 must-pass measures

Tier 3: 130 or more points and all 10 must-pass measures

Important Note:

Any clinic applying for PCPCH recognition must review the technical specifications prior to submitting an application. The technical specifications

describe each measure in more detail, including what documentation the clinic must have to support their attestation. Clinics must have all

services, processes, and policies they attest to in place at the time the PCPCH application is submitted.

The technical specifications for the 2014 criteria will be available mid-September 2013.

2

PCPCH CORE ATTRIBUTE Unchanged

or New? Must Pass?

Points Available

PCPCH Standard

PCPCH Measures

CORE ATTRIBUTE 1: ACCESS TO CARE - “Health care team, be there when we need you.”

Standard 1.A) In-Person Access

1.A.1 PCPCH surveys a sample of its population on satisfaction with in-person access to care.

Unchanged No 5

1.A.2 PCPCH surveys a sample of its population using one of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey tools on patient satisfaction with access to care.

Unchanged No 10

1.A.3 PCPCH surveys a sample of its population using one of the CAHPS survey tools, and meets a benchmark on patient satisfaction with access to care.

Unchanged No 15

Standard 1.B) After Hours Access

1.B.1 PCPCH offers access to in-person care at least 4 hours weekly outside traditional business hours.

Unchanged No 5

Standard 1.C) Telephone and Electronic Access

1.C.0 PCPCH provides continuous access to clinical advice by telephone. Unchanged Yes 0

1.C.1 When patients receive clinical advice via telephone, these telephone encounters (including after-hours encounters) are documented in the patient’s medical record.

New No 5

Standard 1.D) Same Day Access

1.D.1 PCPCH provides same day appointments. New No 5

Standard 1.E) Electronic Access

1.E.3 Using a method that satisfies either Stage 1 or Stage 2 meaningful use measures, the PCPCH provides patients with an electronic copy of their health information upon request.

New No 15

Standard 1.F) Prescription Refills

1.F.1 PCPCH tracks the time to completion for prescription refills. New No 5

CORE ATTRIBUTE 2: ACCOUNTABILITY - “Take responsibility for making sure we receive the best possible health care.”

Standard 2.A) Performance & Clinical Quality 2.A.0 PCPCH tracks one quality metric from the core or menu set of PCPCH Quality Measures. Unchanged Yes 0

3

PCPCH CORE ATTRIBUTE Unchanged

or New? Must Pass?

Points Available

PCPCH Standard

PCPCH Measures

2.A.2 PCPCH tracks and reports to the OHA two measures from the core set and one measure from the menu set of PCPCH Quality Measures. (D)

Unchanged No 10

2.A.3 PCPCH tracks, reports to the OHA and meets benchmarks on two measures from the core set and one measure from the menu set of PCPCH Quality Measures. (D)

Unchanged No 15

Standard 2.B) Public Reporting

2.B.1 PCPCH participates in a public reporting program for performance indicators. New No 5

2.B.2 Data collected for public reporting programs is shared within the PCPCH (with providers and staff) for improvement purposes.

New No 10

Standard 2.C) Patient and Family Involvement in Quality Improvement

2.C.1 PCPCH involves patients, caregivers, and patient-defined families as advisors on at least one quality or safety initiative per year.

New No 5

2.C.2 PCPCH has established a formal mechanism to integrate patient, caregiver, and patient-defined family advisors as key members of quality, safety, program development and/or educational improvement activities.

New No 10

2.C.3 Patient, caregiver, and patient-defined family advisors are integrated into the PCPCH and function in peer support or in training roles.

New No 15

Standard 2.D) Quality Improvement

2.D.1 PCPCH uses performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience.

New No 5

2.D.2 PCPCH utilizes improvement teams that are multi-disciplinary and meet regularly to review timely, actionable, team-level data related to their chosen improvement project and documents their progress.

New No 10

2.D.3 PCPCH has a documented clinic-wide improvement strategy with performance goals derived from community, patient, family, caregiver, and other team feedback, publicly reported measures, and areas for clinical and operational improvement identified by the practice. The strategy includes a quality improvement methodology, multiple improvement related projects, and feedback loops for spread of best practice.

New No 15

4

PCPCH CORE ATTRIBUTE Unchanged

or New? Must Pass?

Points Available

PCPCH Standard

PCPCH Measures

Standard 2.E) Ambulatory Sensitive Utilization

2.E.1 PCPCH obtains information necessary to track selected utilization measures most relevant to their overall or an at-risk patient population.

New No 5

2.E.2 PCPCH reports to the OHA selected utilization measures, and sets goals and works to optimize utilization through: monitoring selected measures on a regular basis, and enacting evidence-based strategies to promote appropriate utilization. (D)

New No 10

2.E.3 PCPCH reports to the OHA selected utilization measures, and shows improvement or meets a benchmark on selected utilization measures. (D)

New No 15

CORE ATTRIBUTE 3: COMPREHENSIVE WHOLE-PERSON CARE - “Provide or help us get the health care, information, and services we need.”

Standard 3.A) Preventive Services

3.A.1 PCPCH routinely offers or coordinates recommended age and gender appropriate preventive services based on best available evidence.

Unchanged1 No 5

3.A.2 PCPCH routinely offers or coordinates recommended age and gender appropriate preventive services, and has an improvement strategy in effect to address gaps in preventive services offerings as appropriate for the PCPCH patient population.

New No 10

3.A.3 PCPCH routinely offers or coordinates 90% of all recommended age and gender appropriate preventive services.

New No 15

Standard 3.B) Medical Services

3.B.0 PCPCH reports that it routinely offers all of the following categories of services: Acute care for minor illnesses and injuries; Ongoing management of chronic diseases including coordination of care; Office-based procedures and diagnostic tests; Patient education and self-management support.

Unchanged Yes 0

Standard 3.C) Mental Health, Substance Abuse, & Developmental Services (check all that apply) 3.C.0 PCPCH has a screening strategy for mental health, substance use, or developmental conditions and documents on-site and local referral resources.

Unchanged Yes 0

1 The intent of this measure has not changed, but the language has been clarified.

5

PCPCH CORE ATTRIBUTE Unchanged

or New? Must Pass?

Points Available

PCPCH Standard

PCPCH Measures

3.C.2 PCPCH has a cooperative referral process with specialty mental health, substance abuse, or developmental providers including a mechanism for co-management as needed.

Unchanged2 No 10

3.C.3 PCPCH is co-located either actually or virtually with specialty mental health, substance abuse, or developmental providers.

Unchanged No 15

Standard 3.D) Comprehensive Health Assessment & Intervention

3.D.1 PCPCH provides comprehensive health assessment and interventions, when appropriate, for at least three health risk or developmental promotion behaviors.

Unchanged No 5

Standard 3.E) Preventive Services Reminders

3.E.1 PCPCH uses patient information, clinical data, and evidence-based guidelines to generate lists of patients who need reminders and to proactively advise patients/families/caregivers and clinicians of needed services.

New No 5

3.E.2 PCPCH tracks the number of unique patients who were sent appropriate reminders. New No 10

3.E.3 Using a method that satisfies either Stage 1 or Stage 2 meaningful use measures, the PCPCH sends reminders to patients for preventative/follow-up care.

New No 15

CORE ATTRIBUTE 4: CONTINUITY - “Be our partner over time in caring for us.”

Standard 4.A) Personal Clinician Assigned

4.A.0 PCPCH reports the percentage of active patients assigned to a personal clinician or team. (D)

Unchanged Yes 0

4.A.3 PCPCH meets a benchmark in the percentage of active patients assigned to a personal clinician or team. (D)

Unchanged No 15

Standard 4.B) Personal Clinician Continuity

4.B.0 PCPCH reports the percent of patient visits with assigned clinician or team. (D) Unchanged Yes 0

4.B.2 PCPCH tracks and improves the percent of patient visits with assigned clinician or team. (D)

New No 10

2 The intent of this measure has not changed, but the language has been clarified.

6

PCPCH CORE ATTRIBUTE Unchanged

or New? Must Pass?

Points Available

PCPCH Standard

PCPCH Measures

4.B.3 PCPCH meets a benchmark in the percent of patient visits with assigned clinician or team. (D)

Unchanged No 15

Standard 4.C) Organization of Clinical Information

4.C.0 PCPCH maintains a health record for each patient that contains at least the following elements: problem list, medication list, allergies, basic demographic information, preferred language, BMI/BMI percentile/growth chart as appropriate, and immunization record; and updates this record as needed at each visit.

Unchanged Yes 0

Standard 4.D) Clinical Information Exchange

4.D.3 PCPCH shares clinical information electronically in real time with other providers and care entities (electronic health information exchange).

Unchanged No 15

Standard 4.E) Specialized Care Setting Transitions

4.E.0 PCPCH has a written agreement with its usual hospital providers or directly provides routine hospital care.

Unchanged Yes 0

Standard 4.F) Planning for Continuity

4.F.1 PCPCH demonstrates a mechanism to reassign administrative requests, prescription refills, and clinical questions when a provider is not available.

New No 5

Standard 4.G) Medication Reconciliation

4.G.1 Upon receipt of a patient from another setting of care or provider of care (transitions of care) the PCPCH performs medication reconciliation.

New No 5

4.G.2 PCPCH tracks the percentage of patients whose medication regimen is reconciled. New No 10

4.G.3 Using a method that satisfies either Stage 1 or Stage 2 meaningful use measures, the PCPCH performs medication reconciliation for patients in transition of care.

New No 15

CORE ATTRIBUTE 5: COORDINATION AND INTEGRATION - “Help us navigate the health care system to get the care we need in a safe and timely way.”

Standard 5.A) Population Data Management (check all that apply)

5.A.1a PCPCH demonstrates the ability to identify, aggregate, and display up-to-date data regarding its patient population.

Unchanged No 5

7

PCPCH CORE ATTRIBUTE Unchanged

or New? Must Pass?

Points Available

PCPCH Standard

PCPCH Measures

5.A.1b PCPCH demonstrates the ability to identify, track and proactively manage the care needs of a sub-population of its patients using up-to-date information.

Unchanged No 5

Standard 5.B) Electronic Health Record

5.B.3 PCPCH has a certified electronic health record and the PCPCH practitioners must meet the standards to be “meaningful users” of certified electronic health record technology established by the Centers for Medicare and Medicaid Services.

Unchanged3 No 15

Standard 5.C) Complex Care Coordination (check all that apply)

5.C.1 PCPCH assigns individual responsibility for care coordination and tells each patient or family the name of the team member responsible for coordinating his or her care.

Unchanged No 5

5.C.2 PCPCH describes and demonstrates its process for identifying and coordinating the care of patients with complex care needs.

Unchanged No 10

5.C.3 PCPCH develops an individualized written care plan for patients and families with complex medical or social concerns. This care plan should include at least the following: self management goals; goals of preventive and chronic illness care; and action plan for exacerbations of chronic illness.

Unchanged4 No 15

Standard 5.D) Test & Result Tracking

5.D.1 PCPCH tracks tests ordered by its clinicians and ensures timely and confidential notification or availability of results to patients and families with interpretation, as well as to ordering clinicians.

Unchanged No 5

Standard 5.E) Referral & Specialty Care Coordination (check all that apply)

5.E.1 PCPCH tracks referrals to consulting specialty providers ordered by its clinicians, including referral status and whether consultation results have been communicated to patients and/or caregivers and clinicians.

Unchanged5 No 5

3 The intent of this measure has not changed, but the language has been clarified. 4 This measure was included in the 2011 criteria under Standard 5F; the intent has not changed, but language is clarified and reorganized under 2014 Standard 5.C. 5 The intent of this measure has not changed, but the language has been clarified.

8

PCPCH CORE ATTRIBUTE Unchanged

or New? Must Pass?

Points Available

PCPCH Standard

PCPCH Measures

5.E.2 PCPCH demonstrates active involvement and coordination of care when its patients receive care in specialized settings (hospital, SNF, long term care facility).

Unchanged6 No 10

5.E.3 PCPCH tracks referrals and cooperates with community service providers outside the PCPCH, such as dental, educational, social service, foster care, public health, non-traditional health workers and pharmacy services.

Unchanged7 No 15

Standard 5.F) End of Life Planning

5.F.O PCPCH has a process to offer or coordinate hospice and palliative care and counseling for patients and families who may benefit from these services.

Unchanged Yes 0

5.F.1 PCPCH has a process to engage patients in end-of-life planning conversations and completes advance directive and other forms such as POLST that reflect patients’ wishes for end-of-life care; forms are submitted to available registries (unless patients’ opt out).

New No 5

CORE ATTRIBUTE 6: PERSON AND FAMILY CENTERED CARE - “Recognize that we are the most important part of the care team - and that we are ultimately responsible for our overall health and wellness.”

Standard 6.A) Language / Cultural Interpretation

6.A.0 PCPCH offers and/or uses either providers who speak a patient and family’s language at time of service in-person or telephonic trained interpreters to communicate with patients and families in their language of choice.

Unchanged Yes 0

6.A.1 PCPCH translates written patient materials into all languages spoken by more than 30 households or 5% of the practice’s patient population.

New No 5

Standard 6.B) Education & Self-Management Support

6.B.1 PCPCH has a process for identifying patient-specific educational resources and providing those resources to patients when appropriate.

Unchanged8 No 5

6.B.2 More than 10% of unique patients are provided patient-specific education resources. New No 10

6 This measure was included in the 2011 criteria as measure 5.E.1.b; the intent has not changed, but language is clarified and reorganized as measure 5.E.2. 7 The intent of this measure has not changed, but the language has been clarified. 8 The intent of this measure has not changed, but the language has been clarified.

9

PCPCH CORE ATTRIBUTE Unchanged

or New? Must Pass?

Points Available

PCPCH Standard

PCPCH Measures

6.B.3 More than 10% of unique patients are provided patient-specific education resources and self-management services.

New No 15

Standard 6.C) Experience of Care

6.C.1 PCPCH surveys a sample of its patients and families at least annually on their experience of care. The patient survey must include questions on access to care, provider or health team communication, coordination of care, and staff helpfulness. The recommended patient experience of care survey is one of the CAHPS survey tools.

Unchanged No 5

6.C.2 PCPCH surveys a sample of its population at least annually on their experience of care using one of the CAHPS survey tools. The patient survey must at least include questions on provider communication, coordination of care, and practice staff helpfulness.

Unchanged9 No 10

6.C.3 PCPCH surveys a sample of its population at least annually on their experience of care using one of the CAHPS survey tools and meets benchmarks on the majority of the domains regarding provider communication, coordination of care, and practice staff helpfulness.

Unchanged10 No 15

Standard 6.D) Communication of Rights, Roles, and Responsibilities

6.D.1 PCPCH has a written document or other educational materials that outlines PCPCH and patient/family rights, complaint, and grievance procedures; roles and responsibilities; and has a system to ensure that each patient or family receives this information at the onset of the care relationship.

New No 5

9 The intent of this measure has not changed, but the language has been clarified. 10 The intent of this measure has not changed, but the language has been clarified.